A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
A client who reports luchia rubra requiring changing perineal pads every 3 hr
A client who has a urinary output of 300 mL in 8 hr
A client who is receiving magnesium sulphate and has absent deep tendon reflexes
A client who reports abdominal cramping during breastfeeding
The Correct Answer is C
A. A client who reports lochia rubra requiring changing perineal pads every 3 hr: Lochia rubra is the normal discharge during the early postpartum period. Changing perineal pads every 3 hours is within the expected range and does not warrant immediate notification of the provider.
B. A client who has a urinary output of 300 mL in 8 hr: Although the urinary output is relatively low, the information provided is not sufficient to conclude that this is abnormal. Further assessment is needed, and this finding alone may not be an emergency. However, it should be monitored.
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes: Absent deep tendon reflexes can be a sign of magnesium toxicity. Magnesium sulfate is used for various indications, such as preeclampsia or eclampsia, but it has a narrow therapeutic range. Absent deep tendon reflexes suggest the need for immediate attention and notification of the provider.
D. A client who reports abdominal cramping during breastfeeding: Abdominal cramping during breastfeeding is a common postpartum symptom associated with uterine contractions. It is a normal physiological response and does not require immediate notification of the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fortified soy milk: Fortified soy milk is a good source of vitamin B12, which is important, especially for individuals following a vegan diet. Vitamin B12 is primarily found in animal products, so those on a vegan diet need to obtain it through fortified foods or supplements.
B. Brown rice: Brown rice is not a significant source of vitamin B12. While it contains other B vitamins, it lacks B12, which is vital for neurological health and the production of red blood cells.
C. Raw carrots: Carrots do not contain vitamin B12. They are rich in beta-carotene (a precursor to vitamin A) and provide other vitamins and minerals, but they are not a source of B12.
D. Fresh citrus fruits: Citrus fruits, like oranges and grapefruits, are good sources of vitamin C, but they do not contain vitamin B12. Vitamin C is important for the absorption of non-heme iron, which is found in plant-based foods, but it does not provide B12.
Correct Answer is C
Explanation
A. Epicanthal folds: Epicanthal folds are the skin folds of the upper eyelid covering the inner corner of the eye. These folds are a normal anatomical variation and are not typically related to forceps-assisted births.
B. Depressed anterior fontanel: A depressed fontanel (the soft spot on a baby's head) might indicate dehydration or a potential concern but is not directly associated with forceps use during birth.
C. Facial asymmetry
Forceps-assisted births involve the use of forceps to aid in the delivery of the baby's head. Facial asymmetry can occur as a result of the pressure applied by the forceps during the birth process. This pressure might cause temporary facial bruising or swelling, leading to an asymmetrical appearance, particularly in the immediate post-birth assessment.
D. Uneven gluteal skinfolds: Uneven gluteal skinfolds, which refer to asymmetry in the skinfolds of the buttocks, are not typically linked to forceps use during delivery. This finding might be a normal variation or could indicate other unrelated conditions.
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